Surgical Treatment of Chronic Type B Aortic Dissection: Open Repair is preferred (for treatment of TAAA) Richard P. Cambria, M.D. Systems Chief Vascular Services, and Chief of Vascular and Endovascular Surgery, Steward Health Care System and St. Elizabeth Medical Center, Boston MA. Robert R. Linton MD Professor of Vascular and Endovascular Surgery, Harvard Medical School (Emeritus) 1 Chronic Type B Dissections What are the questions?? • Current Management of TAAA of Chronic Dissection Etiology • The Evolving Role of TEVAR in chronic TBD Treat or prevent aneurysm ? 2 1
Background Branch Compromise Aortic + 18/20 (90) 34/38 (89) NS 30/178 (17) p<.0001 Rupture - 38/84 (45) Cambria et al. JVS 1988:7 3 The Landscape • LATE SURVIVAL SIGNIFICANTLY IMPROVED WITH INTERVENTION VS MEDICAL THERAPY ALONE • DATA AVAILABLE AT RISK PATIENTS • PROSPECTIVE “REAL WORLD” DATA EMERGING SVS VQI/ FDA PROJECT J Vasc Surg2016;64:1558-59 4 2
MGH Series • 298 Type B pts initially RX with Med Rx • “Failure” defined any death or aortic intervention Overall in 58% of pts • @ 6 years survival better (76 vs 58%, p=.01) in those WITH INTERVENTION J Vasc Surg2015;61:1192-9 5 • CALIF ADMIN DATABASE STUDY OF 9, 165 PATIENTS WITH uTBAD (2000-10) • SIGNIFICANT (P<.01) SURVIVAL BENEFIT FOR TEVAR @ 1 AND 5 YEARS VS. MEDICAL RX ALONE JVASC Surg 2018; 68 6 3
Objectives • Innovative project to serve as a pilot program for registry-based post-approval surveillance in collaboration with industry and the FDA • Determine the effectiveness of TEVAR for treating type B dissection (TBD) • Describe the project cohort and 30-day outcomes of TEVAR for both acute (AD) and chronic dissection (CD) patients 7 JVASC Surg 2019: 69; 680 8 4
Chronic TBD in a 30 yr old RN 9 Anatomy of CTBD in VQI Registry Study 78 % Proximal DTA Zone Maximal Diameter 10 5
Anatomy of Distal Dissections Entry tear - distal to left subclavian artery Rupture at entry site is RARE in absence of localized aneurysmal dilatation Anatomic foundation of medical Rx for distal dissections. 11 Chronic Phase after TBD • Aneurysmal degeneration of outer wall false lumen is the principle late complication Implications for CT surveillance, B- • Continued patency of false lumen blockade + BP control flow is demonstrated risk factor anatomic high risk factors • 40-50% of pts irrespective of initial surgical vs. medical Rx will require interval aortic resection for aneurysm 12 6
MGH Data • 245 pts with uTBD managed medically with mean f/u of 6.8 yrs! • 38% required intervention in f/u PREDICTORS → Entry tear ˃ 10mm (OR 2.1) → Total Ao diameter ˃40mm (OR 2.2) → F lumen diameter ˃ 20 mm • Complete F lumen thrombosis → protective J Vasc Surg 2017: 1-7 13 The Problem Defined • Delivered as the John Homans ’ Lecture at SVS 1982 • 30% of late deaths 2 ° ruptured aneurysms • 30% had secondary surgery for chronic aneurysm formation Surgery 1982;92(6):118-34 14 7
• 200 pts with initial medical Rx of TBD → mean f/u 5 years! ➢ only 50% free from aortic expansion ➢ Mean annual growth 12.3mm Ao diameter ➢ 28% had intervention (most open) for aneurysm of chronic dissection etiology J Vasc Surg 2015;62:900-6 15 Treatment Principles • Medical therapy is 1 treatment of Type B dissections Equivalent results surgery (high mortality) [Glover et al. Circulation 1990:82 Supp IV] • Anatomic goal of eliminating short and long-term complications could be met with minimally invasive approach to seal entry tear 16 8
Pathology — Specific Stent Graft Construct of Type B Dissection ROLE OF UNCOVERED STENTS ENTRY TEAR DISTAL BARE STENTS REMODEL AORTA Coming in 2019! 17 Chronic Aneurysm The Genuine Challenge for TEVAR Principles of aneurysm resection apply → more difficult than treatment with TEVAR in acute phase → open surgery 18 9
Thoracoabdominal Aneurysm of Chronic Dissection Etiology Why is Open Surgery Preferred ? 19 TAAA of Chronic Dissection Etiology • Patients often young (mean 64 years) • Syndromic conditions common (15 % ) • Over past decade 30 % TAAA surgery for chronic dissection aneurysms • Durability considerations are VITAL 20 10
TAA OUTCOMES: EFFECT OF CHRONIC DISSECTION • No differences in periop mortality • No differences in paraplegia (7% vs 5%) J Vasc Surg 2011;53:600-7 21 Survival 100 Dissection 80 Degenerative % Survival 60% 47% 60 40 56% 20 p=0.049 28% 0 0 2 4 6 8 10 12 14 16 Years 22 11
Impact of Collateral Network Concept • Refined techniques for spinal cord protection • Operative mortality for Extent I-III TAA under 5% J Vasc Surg2011;53:1195-201 23 Shift in Spinal Cord Protection • Support of the cord collateral network with distal aortic perfusion (LA- femoral Bpass) • Monitoring of MEVOP during sequential clamping 24 12
Current Results J Vasc Surgery 2013; 58:283-290 25 Results - Outcomes Clamp/Sew DAP/MEVOP Variable p (n=385) (n=100) Intra-op Death 0.5% 1.0% 0.501 Early Post-op Early Post-op Death 9.9% 4.0% 0.072 9.9% 4.0% 0.072 Death Hospital LOS (d) 21.6 + 23.5 19.9 + 12.6 0.492 Permanent SCI 11.9% 3.0% 0.008 Perm SCI/Death 19.1% 7.0% 0.003 Permanent SCI 11.9% 3.0% 0.008 ARF with HD 11.4% 5.1% 0.063 26 13
Durability of Open Surgical Repair of Type I-III Thoracoabdominal aortic aneurysm JVASC Surg April 2019; 1-11 27 TAA Repair: Late Results • At 5 years after open operation, permanent loss of functional capacity occurred rarely J Vasc Surg 2008;48:828-35 28 14
JVASC Surg Jan 2019; 296-302 29 30 15
Conclusion TEVAR FOR TYPE B DISSECTION • Preferred Rx for Acute Comp TBD • Evolving Role in uncomplicated TBD shows promise and being studied • “Experimental” for Rx of Established TAAA of chronic dissection Etiology 31 16
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